Pursuing Universal Health Coverage in the Middle East and North Africa:

Lessons for Low and Middle Income Countries in Asia Presented by: Dr. Eduardo Banzon
Disclaimer: The views expressed in this paper/presentation are the views of the author and do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequence of their use. Terminology used may not necessarily be consistent with ADB official terms.

Universal Health Coverage

all people with access to needed health services (including
prevention, promotion, treatment and rehabilitation) that is of sufficient quality to be effective

use of these services does not expose the user to financial

hardship

three dimensions of coverage

Population Services Financial (protection)

Three dimensions of UHC

UHC is not only about Health Financing

Inputs & processes Health Financing Health workforce Infrastructure Information Governance Service Delivery Outputs Service access and readiness Service quality and safety Service Utilization Prepaid funds

Outcomes Coverage of interventions Coverage with a method of financial risk protection Risk factors

Impact Health Status Household Financial wellbeing Responsiveness

Level and distribution (Equity)

Social Determinants

Middle East and North Africa (Eastern Mediterranean Region)

Share of outofpocket expenditure in total health expenditure, 2010

90 80

70
60 50 40 30

20
10 0

Services coverage MDG health services

Country Group Measles coverage
(Vaccination services)

DOTS coverage
(anti-TB services)

ART coverage % >15 yrs

(Treatment of HIV cases)

Antenatal visits coverage

(ANC services)

Births by SBA
(Maternal Health services)

CPR
(contraceptive services)

High income Middle Income Low Income

98100
9199

100

NA
13-56

98100
66100

98100
74100

2437
3860

100

(data from 4 countries)

6488

47100

9-35
(data from 6 countries)

1779

1987

438

DOTS Directly observed therapy for tuberculosis; ART Antiretroviral therapy; SBA Skilled birth attendants; CPR Contraceptive prevalence rate

Population coverage prepayment arrangements

Country Group Government revenue
All nationals are covered for most/all needed services

Social health insurance Private health schemes (SHI) insurance schemes (PHI)
Nationals are subsidized into SHI schemes in some countries Mandatory for expatriate population in some countries

Other prepayment arrangements

High Income

Middle Income

All citizens are covered to a limited set of services

Formal sector employees, Primary and/or para-statal organizations, supplementary health vulnerable population but insurance for formal covered services are private sector variable employees

Employees of Large employers- through directly provided services Limited community health insurance schemes

Low Income

All citizens are supposed to be covered to a limited set of services

Formal private sector Formal sector employees employees but limited in some countries in scope

Limited community health insurance schemes

LESSONS

RAPIDLY INCREASE POPULATION COVERAGE by TARGETING POPULATION GROUPS

All primary and secondary students

Egypts School Health Insurance Program (SHIP)
Managed by the Health Insurance Organization (HIO) Comprises 41% of the 57% of the population covered by HIO
(23% of total population)

Annual premium
Family pays 4 LE Government pays 12 LE per student Earmarks of 0.10 LE per cigarette pack as supplemental funding

Benefits/Providers
HIO benefits + preventive care funded by Ministry of Health HIO runs around 6000 school clinics

All rural population

Irans Rural Health Insurance program
Managed by Irans Health Insurance Organization

In 2005, all people in rural communities with less than

20,000 people were covered with government subsidies 23 million people currently covered
Nearly a third of Irans total population Family practice benefit combined with MoHs primary health
care services

All children less than six years of age

Egypts Pre-school children coverage
Managed by the Health Insurance Organization (HIO) Comprises 32 % of the 57% of the population covered by HIO
(18% of total population)

Jordans under 6 coverage

Managed by the Civil Insurance Program CIP covers 41.25% of the total population in 2011 (from 26.4% in
2006) Rapid expansion partly due to government subsidies for all children
less than 6 years of age

All Expatriates
Total Population and estimated migrants in GCC countries 2010

Mandatory health insurance in UAE, Saudi Arabia and Qatar for all expatriates

PRE-PAYMENT EMPOWERS the POOR and VULNERABLE POINT of CARE COVERAGE FAVORS the NON-POOR

Pre-Paying the Poor

Moroccos Le Regime d Assistance Medicale (RAMED)
28% of the total population Poor
3 year card free care in government services Near poor (Vulnerable) pay 120 Dh/person/year with a celling of 600 dh/HH
Free care in government facilities

Tunisias Assistance Medicale Gratuite (AMG)

24% of the total population Poor
5 year Free care card (in government facilities) Near poor (Vulnerable) Reduced rates/ subsidized in government facilities
Pays 20% of the cost of every treatment/admission

Point of Care Coverage

Egypts Program of Treatment for the Expense of the
State
Ended up covering routine hospital care

Jordans Royal Court exemption

Heavily used by non-insured non-poor

Irans Iranian point of care enrolment with the Health

Insurance Organization
Dis-incentivizes insurance enrolment by the informal sector

CONVERGE MoH-funded PRIMARY HEALTH CARE and HEALTH INSURANCEfinanced FAMILY PRACTICE

Family Practice and PHC benefits

Irans Rural Health Insurance program
Converges insurance and MoH funded services HIO funds:
Family practice benefits provided by a general practice physician
Includes outpatient consultation, medicines, diagnostics Gatekeeper for inpatient benefits

MOH finances primary health care service

Building on the Berhaz and the PHC teams of Iran
Vaccinations, TB, malaria and other public health services

FOCUS ON MEDICINES improves FINANCIAL RISK PROTECTION

Different approaches
Pooled procurement
Turkey Jordan

Drug price as part of drug labels Subsidies for drug expenses

Iran (multiple sclerosis, blood disorders, costly illnesses) Tunisia (list of 24 conditions) Jordan ( chronic blood diseases) Palestine (chronic blood diseases)

Drug expenditure as percent of GDP (Jordan), 2007-2011

3.50% 3.00% 2.50%

3.10%

3.08%

2.66%
2.26% 2.09%

2.00%
1.50% 1.00% 0.50% 0.00% 2007 2008 2009 2010 2011

OOP expenditure as percent of THE, Jordan (2007-2011)

40.0% 35.0%

35.8% 31.6%

30.0%
25.0% 20.0% 15.0% 10.0% 5.0% 0.0%

22.7%

22.4%

22.6%

2007

2008

2009

2010

2011

CHANGE IN PUBLIC PHARMACEUTICAL EXPENDITURE (%) in TURKEY

Rate of increase in number of pillboxes %153 Rate of Increase in Pharmaceutical Expenditure

Number of Pillboxes (million) 1994 539 2002 699 2012 1.769

Public Pharmaceutical Expenditure (2012 Prices - million TL) 1994 6.244 2002 14.624 2012 14.484

RE-DEFINE FREE CARE IN GOVERNMENT HEALTH FACILITIES

NOT LIMITED TO THE POOR

No co-payment

Jordans CIP Moroccos RAMED Tunisias AMG and CNAMs public option Sudans NHIF Egypts HIOs Law 79

Fixed co-payment (usually 10%)

Irans HIO and SSO Moroccos CNOPS and CNSS Lebanons CNSS

PROVIDING CHOICE in a SINGLE FUND

Tunisias CNAM
Government provider choice (70% of members)
Services provided by MOH health facilities + CNSS polyclinics and
military hospitals No co-payments for members

Private provider choice (13% of members)

Members are are assigned a private family physician who will refer to
specialist care and hospitalization (usually also private providers) 30% co-payment

Reimbursement of providers choice (17% of members)

Members pay private or public providers first and are then reimbursed
by CNAM Reimbursement up to a ceiling (beyond that- member pays)

Choice is made annually

ENGAGE the PRIVATE SECTOR and RELIGIOUS CHARITIES INNOVATIVELY

Beyond tariffs and banning dual practice

Private sector third party administrator (Medexa) engaged
to deal with private hospitals in Jordan

Private health insurer (Munich Re) brought in as minority

partner (20% equity) in Abu Dhabis National Health Insurance Corporation (DAMAN)
All UAE nationals in Abu Dhabi are enrolled with Daman through the
Thiqa health insurance scheme It also covers expatriates who avail of the Basic Health Package/ Plan

Sudans National Health Insurance Fund and Zakat

Social Initiative Project Zakat (religious alms) trustees and Basic Zakat Communities
identify the poor Subsidizes one third of those enrolled through the Social Initiative
project Ministry of Welfare and Social Security (MoWSS) covers the other two third

By 2016, it is expected that

Zakat will sponsor 380,000 families MoWSS will sponsor 760,000 Families

Currently, 400,000 families are covered through the SIP

46% of total membership of NHIF

CREATE SYNERGIES with SOCIAL SECURITY ORGANIZATIONS

Different Approaches
Moroccos Obligatory Health Insurance law (AMO)
Created a government agency (AMAN) to supervise all health
insurance CNSS (for private sector) and CNOR (for government) benefits are based on AMO. AMAN manages the RAMED scheme

Tunisias outsourcing of premium collection

Social security organizations CNSS (for private sector) and
CNOR (for government employees) collect the premiums as part of social security contributions then transfers it to CNAM CNAM manages engagement with health care providers for CNSS, CNOPS and AMG (for the poor) members

UHC REFORMS CAN RAPIDLY IMPROVE HEALTH OUTCOMES

TURKEY HEALTH TRANSFORMATION

Individual performancebased supplementary payment system implemented in MoH institutions Green Card holders covered for outpatient care SSK pharmacies closed and members allowed to access private facilities

Green Card holders covered for outpatient prescription drugs

Amendments to Social Security and UHI Law adopted by the Grand National Assembly and signed by the President
Family medicine implemented in Elazig, Isparta, Samsun, and Izmir provinces.

SSK hospitals transferred to the MoH

Green Card holders to receive same benefits as enrollees in other health insurance schemes under UHI

Decree in Force of Law no. 663 on the Organization and Duties of the Ministry of Health and Its Affiliates passed establishing the Public Health Institution and Public Hospitals Union and moving the MoH into a stewardship role and away from provision and financing. Decree also establishes positive incentives for NCD prevention and control in family medicine.

2004 2003 2005

2006 2007

2008 2009

2010 2011

2012

Family medicine pilot first implemented in Duzce

Health payments of civil servants and their dependents relocated to SSI Family Medicine implemented countrywide, including Ankara and Istanbul

Green Card program transferred to SSI

Performance-based payments piloted in ten MoH hospitals Global budget implemented for MoH hospitals Implementation of Law 5502 (integration of social security institutions) begins Family medicine implemented in Eskisehir, Edirne, Denizli, Adiyaman and Gumushane provinces

Family Medicine implemented in the provinces of Rize, Trabzon, Tunceli, Uak and Bursa

By 2012 in TURKEY
FINANCE
General Government Budget (MoF)
Primary Health Care

SERVICE PROVISION

MoH
Emergency Transport Public hospitals / Dent. Clinics

Social Security nstution (SSI)

Private Hospitals Regulation And Small Centers PUBLIC Private Physician Offices

Premiums And Co-pays

Pharmacies

Public University Hospitals

(Managed by Council of Higher Education)
6

Health outcomes improved.

Infant Mortality Rate (in 1000)
50 42,7
75 70

Maternal Mortality Rate (in 100.000)

61

29 25

50

25

12,1 10,2 7,8 7,7

19,4 18,4 16,4 15,5

1998

1998

2003

2008 2009 2010 2011

2005

2006 2007 2008 2009 2010 2011

2003